A surgical instrument assembly includes a support frame system, and a surgical tool engageable with the support frame system. The support frame system is adapted for providing a surgical tool attachment and articulation locus that is maintained during the course of a surgical procedure to direct a fixed and repeatable delivery path for introduction and manipulation of one or more surgical instruments and implants at a surgical site in or on the patient's anatomy. The delivery path can be substantially curvilinear along an arc that is defined by a radius of curvature and length defined by the surgical tool, and a predetermined range of articulation of the tool at the articulation locus.
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1. A surgical instrument system, comprising:
(a) a surgical table having first and second ends and a surface suitable to support a surgical subject with the surgical subject oriented along a superior to inferior axis of the surgical table between its first and its second ends;
(b) a rigid support bar that is affixed at a first end to an adjustable pivot assembly and at a second end to a rigid support structure, the adjustable pivot assembly comprising a first lockable sleeve engageable with the rigid support bar passed through the first lockable sleeve, and a second lockable sleeve engagable with a first end of an extender rod passed through the second lockable sleeve, the extender rod comprising an affixed pivot arm that is oriented generally perpendicular to the extender rod and rotatable around a long axis of the extender rod, the pivot arm adapted for fixation to a surgical tool; and
(c) a surgical tool,
wherein the adjustable pivot assembly affixed to the rigid support bar is positionable above the surgical table, and
wherein the surgical tool, when engaged with the adjustable pivot assembly, is adjustably positionable at a point that is defined by an intersection of three axes that are normal to each other and that transect the surgical tool, a first of the three axes being parallel to the superior to inferior axis of the surgical table, a second of the three axes being perpendicular to the superior to inferior axis of the surgical table and in a plane that extends in a lateral dimension that is transverse to the superior to inferior axis of the surgical table, and a third of the three axes being perpendicular to and transecting the superior to inferior axis of the surgical table.
17. A surgical instrument assembly, comprising:
a frame system, and a surgical tool engageable with the frame system,
wherein the frame system is adapted for providing a surgical tool attachment and articulation locus that is maintained during the course of a surgical procedure to direct a fixed and repeatable delivery path for introduction and manipulation of one or more surgical instruments and implants into a surgical site in or on the patient's anatomy, the delivery path being curvilinear along an arc that is defined by a radius of curvature of the surgical tool, a length of an attachment arm of the surgical tool to the rigid support bar, and a predetermined range of articulation of the articulation locus
the frame system comprising
a rigid support bar affixed to a rigid support structure, the support bar having a free end comprising an adjustable pivot assembly to which the surgical tool is affixed, the adjustable pivot assembly providing motion around each one of three axis that are normal to each other and that transect the rigid support bar and adjustable connector, and translational motion along at least two of each of the three axis that are normal to each other and that transect the rigid support bar and adjustable connector;
the adjustable pivot assembly comprising one of (i) parallel oriented first and second lockable sleeves, the first lockable sleeve engageable with the rigid support bar passed through the first lockable sleeve, and a second lockable sleeve engagable with a first end of an extender rod passed through the second lockable sleeve, the extender rod comprising an affixed pivot arm that is oriented generally perpendicular to the extender rod and rotatable around a long axis of the extender rod, the pivot arm adapted for fixation to a surgical too, and (ii) a spherical head at the free end of the rigid support bar and a socket adapted for fixation to the spherical head and to the surgical tool
the surgical tool comprising an attachment feature for releasable fixation to the adjustable pivot assembly
wherein adjustment and locking of the adjustable pivot assembly fixes the point of attachment of the surgical tool.
2. The surgical instrument system according to
3. The surgical instrument system according to
4. The surgical instrument system according to
5. The surgical instrument system according to
6. The surgical instrument system according to
7. The surgical instrument system according to
8. The surgical instrument system according to
9. The surgical instrument system according to
a support base formed of radio translucent material and comprising crosshair-oriented position indicators that extend, with reference to the spine of the surgical subject, in a superior to inferior dimension and a transecting lateral dimension and are formed of radio opaque material;
a vertically adjustable depth indicator that extends from an upper surface of the support base and is formed of radio-translucent material, the depth indicator comprising
a vertically translatable extender with graduated markings in conventional units of measure, an extender lock;
a vertically adjustable and linear pivot arm that extends on an axis that is parallel to the lateral dimension of the position indicators and is adjustable and lockable vertically and which is attached at a first end to the vertically translatable extender and pivots from a position that is parallel with the vertically translatable extender to a position that is perpendicular to the vertically translatable extender,
wherein, in use, the guidance instrument is positioned on the surgical subject and under fluoroscopy to confirm collinear alignment with the spine along the superior to inferior dimension in a plane that sagittal with respect to the spine of the surgical subject and lateral alignment with a target disc space along the lateral dimension in a plane that is transverse to an axis defined by the spine of the surgical subject, and a vertical height of the pivot arm is selected to approximate centerline of the disc space, whereby the contact point of the arcuate pointer on an external surface of the surgical subject's skin is selected as an incision site.
10. The surgical instrument system according to
distance from a skin surface above the spinous process to the spinous process,
distance from the top of the spinous process to the anterior margin of the disc,
distance from the top of the spinous process to the posterior margin of the disc,
wherein the height of the vertically adjustable extender is selected to enable travel of the incision guidance instrument pivot arm along the desired radius of curvature.
11. The surgical instrument system according to
12. The surgical instrument system according to 1, comprising a modular surgical retractor comprising, a retractor body and a retractor hood, the retractor body and retractor hood each comprising a proximal end that is adapted to extend outside of the surgical field and a distal end that is adapted to extend into the surgical field, the retractor body and retractor hood engageable to form a through channel disposed between open proximal and distal ends that are defined by the proximal and distal ends of the retractor body and retractor hood, and bounded by the retractor body and retractor hood, the through channel having a central channel axis, the retractor body comprising a floor extending along a retractor body longitudinal axis, and the retractor hood comprising a body extending along a retractor hood longitudinal axis, the retractor hood having a soft tissue elevator at the distal end, and a releasable handle at the proximal end.
13. The surgical instrument system according to
wherein when uncoupled, the retractor hood can be aligned with the retractor body and at least partially compressed against the retractor body, and wherein, when coupled, the retractor body and retractor hood are displaced from one another vertically and constrained to one or more of three degrees of freedom, being movable pivotally around a pivot axis at the proximal end that is perpendicular to the channel longitudinal axis, displaceable vertically from between a compressed orientation up to a pre selected displacement distance, or slidable horizontally along the channel longitudinal axis, or combinations of these.
14. The surgical instrument system according to
the retractor body is substantially curvilinear along its longitudinal axis and has a radius of curvature from 5 to 50 cm;
the distal end of one or both the retractor body and retractor hood is contoured and wherein the contour describes a concave arc that transects the retractor's longitudinal axis and has a radius of curvature from 0.5 cm to 10 cm, and wherein the contour is bounded by bosses;
the retractor hood is rectilinear along its longitudinal axis, and is either rectilinear or bowed around its longitudinal axis along at least a portion of its length;
the retractor body comprises two opposing sidewalls bounding the floor along at least part of the length of the floor, the floor and sidewalls extending along the longitudinal axis and defining a chute with an open top, wherein the retractor body sidewalls are selected from essentially planar and bowed; and,
at least one of the retractor and the hood comprises at least one tissue fixation member, comprising: a retractor securement element and a tissue securement element, the retractor securement element securable to one or both of the retractor body and retractor hood, and the tissue securement element is securable to a target tissue in the surgical field and selected from a screw, a pin, a wire, an awl, and a tang.
15. The surgical instrument system according to
a modular surgical retractor comprising, a retractor body and a retractor hood, the retractor body and retractor hood each comprising a proximal end that is adapted to extend outside of the surgical field and a distal end that is adapted to extend into the surgical field, the retractor body and retractor hood engageable to form a through channel disposed between open proximal and distal ends that are defined by the proximal and distal ends of the retractor body and retractor hood, and bounded by the retractor body and retractor hood, the through channel having a central channel axis, the retractor body comprising a floor extending along a retractor body longitudinal axis, and the retractor hood comprising a body extending along a retractor hood longitudinal axis, each of the retractor body and retractor hood being independently operable to manipulate soft tissue and adapted to be adjustably and releasably coupled at their proximal ends with general alignment of their respective longitudinal axes, the retractor body and the retractor hood each comprising at its proximal end a coupling element for adjustably and releasably coupling the retractor body and retractor hood, one of the coupling elements comprising one or a plurality of fasteners, and the other of the coupling elements comprising one or a plurality of receivers,
wherein when uncoupled, the retractor hood can be aligned with the retractor body and at least partially compressed against the retractor body, and wherein, when coupled, the retractor body and retractor hood are displaced from one another vertically and constrained to one or more of three degrees of freedom, being movable pivotally around a pivot axis at the proximal end that is perpendicular to the channel longitudinal axis, displaceable vertically from between a compressed orientation up to a pre selected displacement distance, or slidable horizontally along the channel longitudinal axis, or combinations of these.
16. The surgical instrument system according to
the retractor body is substantially curvilinear along its longitudinal axis and has a radius of curvature from 5 to 50 cm;
the distal end of one or both the retractor body and retractor hood is contoured and wherein the contour describes a concave arc that transects the retractor's longitudinal axis and has a radius of curvature from 0.5 cm to 10 cm, and wherein the contour is bounded by bosses;
the retractor hood is rectilinear along its longitudinal axis, and is either rectilinear or bowed around its longitudinal axis along at least a portion of its length;
the retractor body comprises two opposing sidewalls bounding the floor along at least part of the length of the floor, the floor and sidewalls extending along the longitudinal axis and defining a chute with an open top, wherein the retractor body sidewalls are selected from essentially planar and bowed; and,
at least one of the retractor and the hood comprises at least one tissue fixation member, comprising: a retractor securement element and a tissue securement element, the retractor securement element securable to one or both of the retractor body and retractor hood, and the tissue securement element is securable to a target tissue in the surgical field and selected from a screw, a pin, a wire, an awl, and a tang.
18. The surgical instrument assembly according to
19. The surgical instrument assembly according to
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This application is a continuation-in-part of, and claims priority to U.S. patent application Ser. No. 15/747,935 that was filed on Jan. 26, 2018, now U.S. Pat. No. 10,687,830 Issued on Jun. 23, 2020, which is a 35 USC 371 US National Stage application of International Patent Application No. PCT/US2016/044119 that was filed on Jul. 26, 2016 having a priority date of Jul. 26, 2015, and which claims the benefit under 35 U.S.C. § 119(e) and priority to U.S. Provisional Application Ser. Nos. 62/197,093 filed Jul. 26, 2015, and 62/246,566 filed Oct. 26, 2015, and which is also a continuation in part of U.S. patent application Ser. No. 14/791,881 filed Jul. 6, 2015, now U.S. Pat. No. 10,045,768 issued on Aug. 14, 2018, and is related to and claims priority as continuation in part to U.S. patent application Ser. No. 16/028,817 filed Jul. 6, 2018, which is a divisional of U.S. patent application Ser. No. 14/791,881 each of which claim the benefit under 35 U.S.C. § 119(e) to U.S. Provisional Application Ser. No. 62/021,202 filed Jul. 6, 2014, and Nos. 62/080,609, 62/080,573, 62/080,578, 62/080,590, 62/080,557, all filed Nov. 17, 2014, and No. 62/156,184, filed May 1, 2015, the entireties of which are incorporated herein by reference.
The present application describes various exemplary devices, systems and surgical techniques for achieving access to a site within the body, particularly the spine. More particularly, the present application describes a system and device components useful for accessing the spine for one or more purposes of manipulation, removal, replacement and reinforcement of intervertebral discs, particularly in the lumbar spine.
Delivery of spinal devices is typically achieved using a variety of instruments that penetrate, dilate, retract and distract soft and bony tissue. Often these systems involve the use of clamps supports and other systems for temporarily holding and fixing placement of instruments relative to the patient. And common to the use of many of the surgical instruments is manipulation of tissue by pounding or banging on handles and strike plates to drive motion of instruments or implants through or into the tissue, particularly for distracting bones and inserting implants into bones. There is need in the art for instrument delivery systems and devices that enable precise and repeatable targeting of instruments and implants to the tissue and that dissipate or dampen the concussive effects associated with clinical techniques, particularly those used in orthopedic and spinal surgery.
In accordance with the disclosure, a surgical instrument assembly is provided that includes a support system, and a surgical tool engageable with the support system. The support frame is adapted for providing a surgical tool attachment and articulation locus that is maintained during the course of a surgical procedure to direct a fixed and repeatable delivery path for introduction and manipulation of one or more surgical instruments and implants into a surgical site in or on the patient's anatomy, the delivery path being substantially curvilinear along an arc that is defined by a radius of curvature of the surgical tool, a length of an attachment arm of the surgical tool to the support bar, and a predetermined range of articulation of the articulation locus.
In some embodiments, the present invention provides methods for performing a procedure on the spine of a patient utilizing the surgical systems hereof to enable controlled and reliable delivery of instruments and implants into the spine along a predetermined and controlled path.
Embodiments of the present invention are not limited to use in a posterior-lateral approach for spinal surgery, and in other orientations and other surgical sites within the body.
Features and advantages of the general inventive concepts will become apparent from the following description made with reference to the accompanying drawings, including drawings represented herein in the attached set of figures, of which the following is a brief description:
This disclosure describes exemplary embodiments in accordance with the general inventive concepts and is not intended to limit the scope of the invention in any way. Indeed, the invention as described in the specification is broader than and unlimited by the exemplary embodiments set forth herein, and the terms used herein have their full ordinary meaning.
The general inventive concepts will now be described with occasional reference to the exemplary embodiments of the invention. The general inventive concepts may be embodied in different forms and should not be construed as limited to the embodiments set forth herein. Rather, these embodiments are provided so that this disclosure will be thorough and complete, and will fully convey the scope of the general inventive concepts to those skilled in the art.
As used herein, the singular forms “a,” “an,” and “the” are intended to include the plural forms as well, unless the context clearly indicates otherwise. The term “proximal” as used in connection with any object refers to the portion of the object that is closest to the operator of the object (or some other stated reference point), and the term “distal” refers to the portion of the object that is farthest from the operator of the object (or some other stated reference point). The term “operator” means and refers to any professional or paraprofessional who delivers clinical care to a medical patient, particularly in connection with the delivery of care.
Anatomical references as used herein are intended to have the standard meaning for such terms as understood in the medical community. For example, the application may include reference to the following terms: “cephalad,” “cranial” and “superior” indicate a direction toward the head, and the terms “caudad” and “inferior” indicate a direction toward the feet. Likewise, the terms “dorsal” and “posterior” indicate a direction toward the back, and the terms “ventral” and “anterior” indicate a direction toward the front. And the term “lateral” indicates a direction toward a side of the patient, the term “medial” indicates a direction toward the mid line of the patient, and away from the side, the term “ipsalateral” indicates a direction toward a side that is proximal to the operator or the object being referenced, and the term “contralateral” indicates a direction toward a side that is distal to the operator or the object being referenced. More generally, any and all terms providing spatial references to anatomical features shall have meaning that is customary in the art.
Unless otherwise indicated, all numbers expressing quantities, properties, and so forth as used in the specification, drawings and claims are to be understood as being modified in all instances by the term “about.” Accordingly, unless otherwise indicated, the numerical properties set forth in the specification and claims are approximations that may vary depending on the suitable properties desired in embodiments of the present invention. Notwithstanding that the numerical ranges and parameters setting forth the broad scope of the general inventive concepts are approximations, the numerical values set forth in the specific examples are reported as precisely as possible. Any numerical values, however, inherently contain certain errors necessarily resulting from error found in their respective measurements.
References to visualization using radiography as described in the exemplary techniques herein are merely representative of the options for the operator to visualize the surgical field and the patient in one of many available modalities. It will be understood by one of ordinary skill in the art that alternate devices and alternate modalities of visualization may be employed depending on the availability in the operating room, the preferences of the operator and other factors relating to exposure limits. While confirmation of instrument placement in the course of the technique is appropriate, the frequency and timing relative to the sequence of steps in the technique may be varied and the description herein is not intended to be limiting. Accordingly, more or fewer images, from more or fewer perspectives, may be collected.
One of ordinary skill will appreciate that references to positions in the body are merely representative for a particular surgical approach. Further, according to some of the exemplary embodiments described herein, such references may be based on a representative spinal access modular retractor system having a radius of curvature as described, being suitable for any number of animal patients, including humans and other species. Of course, the type of surgery, target tissue, and species of patient may be different than is disclosed in the exemplary embodiments described herein, and in some embodiments, all or most components of the system may be rectilinear or combinations of rectilinear and curvilinear.
Further, all references herein are made in the context of the representative images shown in the drawings. Fewer or additional instruments, including generic instruments, may be used according to the preference of the operator. Moreover, references herein to specific instruments are not intended to be limiting in terms of the options for use of other instruments where generic options are available, or according to the preference of the operator.
There is a need for devices and systems that overcome the shortcomings in the art pertaining to surgical access, and in some particular instances, minimally invasive surgical access, particularly access for spinal surgery. In view of this need, the embodiments of devices, systems, and surgical methods provided herein address a variety of objects and advantages. The present application describes various exemplary devices, systems and surgical methods for achieving surgical access to a site within the body, particularly the spine. More particularly, the present application describes a system and device components for providing a system for positioning, securing and optimizing surgery with a minimally invasive modular retractor system for directly viewing and accessing a surgical site in the body, particularly the spine. In some exemplary embodiments, the system and device components are useful for accessing the spine for one or more purposes of neural decompression, manipulation, removal, and replacement and reinforcement of intervertebral discs, particularly in the lumbar spine.
Referring now to the drawings,
In certain embodiments, the modular retractor system is suitable for facilitating placement of one or more implants to achieve interbody fusion between adjacent vertebrae, and in particular, lumbar interbody fusion. Referring to the representative embodiment of the modular retractor system shown in
Advantageously, in certain embodiments, a curvilinear shape of the direct visualization modular retractor system 100, as depicted in
While various features and aspects of the modular retractor may vary according to the disclosure, in some embodiments of the instant invention, the modular retractor components are particularly suited for posterior-lateral access to the spine, wherein one or more components has a generally curved profile, being curved along an elongate axis. In yet other embodiments, the devices and systems are particularly suited for a surgical procedure that is achieved along a generally rectilinear (i.e., uncurving) path, such as via a direct anterior, posterior, or lateral approach wherein suitable embodiments of the device and system components are essentially rectilinear, or have a nominal curvature with a radius of curvature.
Of course, it will be appreciated that other modes of access to the spine can also be achieved, particularly with alternate retractor systems, and in particular, non-curvilinear embodiments of the modular retractor system, as described herein below. Likewise, it will be appreciated that any one or more of a variety of surgical procedures can be performed through various embodiments of a direct visualization modular retractor system, including but not limited to, removal of annulus material, vertebral distraction, graft and/or interbody implant insertion, and attachment of one or more plates and/or screws. In addition to enabling direct visualization for a lateral approach to the spine, other specific features and advantages of the modular retractor system and the surgical technique are described further herein. In particular, as provided herein, use of a modular retractor system with one or more of surgical guidance instruments and support frames allow enhanced precise targeting and control of surgical access that provide the benefits of improved options for implant placement and to reduction or elimination of the concussive effects on the clinician and the patient that are common with spinal surgery.
Surgical Guidance
In accordance with various embodiments, systems, techniques and instruments are provided that facilitate selection of incision site on the exterior of a patient's anatomy, selection of entry site on a target within the patient's anatomy, for example, entry into the disc space, and reliable positioning and path control for insertion of one or more instruments for accessing a target within a patient's anatomy.
In accordance with various embodiments herein, surgical guidance may be achieved using one or more support frame 200 systems together with one or more surgical tools or instruments, including but not limited to, trajectory guide arms, incision guidance instruments, tissue manipulation instruments, anatomically contoured implants, and combinations of these.
Support Frame
In various embodiments as depicted in the drawings a support frame 200 is provided which is attachable to a surgical table and is used for securing surgical instruments to stably position them during surgery and to enable dissipation of concussive force during soft and bony tissue procedures. The support frame 200 includes conventional surgical support frame 200 elements together with novel elements that enable concussive forces to be dissipated across the support frame 200. In various embodiments, the support frame 200 is adapted with various clamps for affixing instruments to the rails and includes attachable bolsters that can be positioned adjacent to a patient's body parts to brace the body tissue and provide counter resistance during instrument manipulation.
Referring now to
In some embodiments, the attachment of the support bar 220 to the cross bar 210 allows adjustment in two planes, vertically and laterally. In yet other embodiments, attachment of the support bar 220 to the cross bar 210 may be a swivel type, that allows for multiple degrees of freedom, wherein the support bar 220 is affixed to the cross bar 210 with a clamp that allows rotational freedom around the axis of the cross bar 210, rotational freedom around the axis of the support bar 220, and rotational freedom around an axis that is perpendicular to the axis of the cross bar 210. Exemplary drawings of such a cross bar 210 affixed to a support frame 200 system are shown in
In accordance with various embodiments, the support frame 200 system and cross or parallel bars are used to support instruments for directing access to anatomical targets, such as the spine. Referring again to the drawings, for example, the embodiment of the invention as shown in
According to some embodiments, the support bar 220 is configured at a second end with a generally spherical head 250 that is adapted to engage with instruments, the generally spherical head 250 allowing for multiple degrees of freedom of engagement and attachment to instruments. Referring now to
It will be appreciated that the support frame 200 components supporting the support bar 220 need not be rigidly aligned relative to the surgical table, and indeed, as shown for example in
Referring now to
In one embodiment a surgical instrument assembly includes a guidance support frame system, for example as shown in
The rigid support bar 220 is adapted at a first end for slidable and lockable engagement with the adjustable connector 230 and is adapted at a second end for lockable engagement with one or more of the adjustable pivot assembly 240 and a surgical tool. The adjustable connector 230 is adapted for engagement with the cross bar 210 and is adjustable to allow positional adjustment of an engaged rigid support bar 220 by one or more ranges of motion. For example, actuation can result in perpendicularly arranged bars where the support bar 220 pitches downward or upward in a vertical direction at its distal end that is not attached to the support bar 220. In another example the support bar 220 may be rotated from between a perpendicular to a near parallel alignment with the cross bar 210. Or the support bar 220 may be translated either along the long axis of the cross bar 210, or transverse to its axis, or combinations of these. Or the support bar 220 may be raised or lowered along a vertical axis relative to the cross bar 210 such that its vertical height relative to the support surface changes.
Thus, in various possible embodiments, the movement of the support bar 220 relative to the cross bar 210 by actuation of the adjustable connector 230 may include one or more of translational adjustment along an elongate axis and between a first and second end of the rigid cross bar 210; translational adjustment along a horizontal axis that is perpendicular to the elongate axis of the rigid cross bar 210; translational adjustment along a vertical axis that is perpendicular to the elongate axis of the rigid cross bar 210; rotational adjustment around the elongate axis of the rigid cross bar 210; rotational adjustment around the vertical axis that is perpendicular to the elongate axis of the rigid cross bar 210; and rotational adjustment around the horizontal axis that is perpendicular to the elongate axis of the rigid cross bar 210. The support frame 200 system also includes one or more surgical tools selected from guidance instruments, retractors and retractor components, and tissue manipulation surgical tools, which are in some embodiments engageable with one or more of the rigid support bar 220 and the adjustable pivot assembly 240.
In some embodiments, any one of the bars of the support frame 200 system and the adjustable connector 230 and adjustable pivot assembly 240 includes a handle configured for manipulation by a user, wherein manipulation of the handle allows the user to releasably adjust the position of any one of the bars of the support frame 200 system.
In some embodiments, the rigid cross bar 210 is adjustable at its attachment to the surgical support surface, and wherein the rigid support bar 220 is adjustable at the adjustable slidable connector.
In some embodiments, the surgical tool is configured for attachment at a first proximal end to one of the rigid support bar 220 and the adjustable pivot assembly 240, and at its distal end with a tissue manipulation implement, wherein a distance between the proximal and distal ends defines a length of the surgical tool.
In some embodiments, for example referring to
In some embodiments, the adjustable pivot assembly 240 comprises a spherical head 250 on the second end of the support bar 220 and an engagable socket 280 that is adapted to engage with the spherical head 250, the socket 280 adapted for fixation to a surgical tool.
In some embodiments, adjustment and locking of the support bar 220 connector effectively fixes in space the position of the adjustable pivot assembly 240, and thereby fixes the point of attachment of the surgical tool, and wherein the position of the pivot assembly is selected to direct a tissue manipulation implement portion of the surgical tool into contact with a target site in or on a surgical subject on the surgical support surface.
In some embodiments, adjustment and locking of the support bar 220 connector effectively fixes in space the position of the adjustable pivot assembly 240, and thereby fixes the point of attachment of the surgical tool, and wherein the position of the pivot assembly is selected to direct a tissue manipulation implement portion of the surgical tool into contact with a target site in or on a surgical subject on the surgical support surface.
In various embodiments, the surgical tool is selected from shims, osteotomes, tissue distractors, and inserters, and instruments for manipulation of one or more of bone screws, plates, interbody devices, and artificial discs, and wherein the surgical tool comprises one or more of an actuator selected from a ratchet or gear system comprising one or more rack and pinion components, a walking beam and plates drive system, and, a threaded rod with a shift for providing rotational force to alternately drive distal and proximal movement.
The various instruments described herein below may be affixed to such support frame 200 system to achieve positioning of a spinal access system, such as the modular retractor system described herein, and manipulation of tissue in preparation for implant delivery.
Surgical Instruments
Trajectory Guide Arm
In some embodiments, a trajectory guide arm is used for one or more of establishing initial entry into the skin (i.e., incision into a patient's anatomy), establishing access to a particular target tissue (e.g., targeting entry point into the lateral margin of a spinal disc space), fixing positioning of a tissue preparation or tissue manipulation tool, and securing and stabilizing delivery of implants, and combinations of these.
Referring generally to the drawings, for example in
Without being limiting, the radius of curvature of instruments according to the disclosure may be within a range from about 0 cm to about 60 cm, and more particularly from about 5 cm to about 25 cm, and in some embodiments the radius may be selected from one of 15 cm, 17 cm, 17.5 cm, 18 cm, 22 cm, 22.5 cm, and 25 cm. Of course other radii are possible within the range from 0 cm to more than 60 cm, including 0, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, and 60, and incremental fractions thereof including 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9 cm.
Incision Guidance Instrument
In some embodiments of the surgical techniques, an incision guidance instrument is used for selecting a desirable incision site for insertion of the modular retractor system to achieve placement at the desired location relative to a target spinal intervertebral space. Referring again to the drawings,
Referring now to
It will be appreciated that the guidance instrument may be used for other surgical contexts beyond the spine, taking advantage of the device's features to identify a desired position within a patient relying on the geometric relationship of the indicators and the arcuate pointer to select an incision site. In use, the guidance instrument is positioned on the surgical subject and under fluoroscopy to confirm collinear alignment of one or more indicators with target tissue. For example, AP fluoroscopy is used to confirm collinear alignment of one or more indicators with the spine along the sagittal plane, and lateral alignment with the target disc space along the transverse plane.
Referring again to
According to the various embodiments, when the base of the guidance instrument is placed in the intended orientation relative to the target tissue, such as the spine, the position indicators extend in superior to inferior and transecting lateral dimensions and are formed of radio opaque material. The instrument also includes a vertically adjustable depth indicator that extends from an upper surface of the support base and is desirably formed of essentially radio-translucent material. In various embodiments, the depth indicator includes a vertically translatable extender 300 with graduated markings in conventional units of measure, or alternatively markings indicating a predetermined position relative to a position of the patient's anatomy. The vertically translatable extender 320 may include an extender lock.
In various embodiments, the height of the vertically translatable extender 320 320′ is selected to enable travel of the incision guidance instrument pivot arm along the desired radius of curvature whereby the arcuate pointer would enter the disc space adjacent to a vertebra of interest at a position that is dorsal to the midline of the disc along the frontal plane, at approximately 30% of the overall disc height (in the AP dimension) from the posterior disc margin, wherein the disc height is measured radiographically, for example using CT radiography, as the distance between the anatomical posterior and anterior disc margins.
It will be appreciated that the locus of entry into the disc space in the AP dimension is selected based upon the particular anatomical features of a human spine and the dimensions of the modular retractor components. Thus, it will be further appreciated that in other embodiments, the entry point for achieving centering relative to another target tissue, including the spine and other anatomical structures within a body, may be varied so as to achieve desired positioning. Thus, as applicable to the spine, the above disclosed selected point of entry at a position that is dorsal to the midline of the disc along the frontal plane, at approximately 30% of the overall disc height (in the AP dimension) from the posterior disc margin is non limiting. Indeed, as otherwise described herein, targeting may be selected for entry into the disc at a position other than 30% of the disc height.
Thus, in other embodiments wherein access to the spine is desired, the entry position may be more dorsal or more ventral, and may be anywhere within the range from 1% to 99% of the overall disc height from the posterior disc margin, including 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, and 99%.
More particularly, the height of the attachment point of the pivot arm to the vertically translatable extender 320 is determined based on one or more anatomical measurements obtained radiographically or manually relative to a vertebra of interest, including one more of a spinous process, anterior and posterior vertebral margins, and associated disc margins. According to some such embodiments, the measurements are selected from distance from a skin surface above the spinous process to the spinous process, distance from the top of the spinous process to the anterior margin of the disc, and distance from the top of the spinous process to the posterior margin of the disc.
In one representative example, wherein the incision site is being selected so as to establish a trajectory to the center of the disc, the distance between the center of the disc (determined, for example, using a CT radiograph—typically about ½ the distance between the anterior and posterior disc margins) to the top of the spinous process is measured, and the distance between the top of the spinous process to the top of the skin is measured, and these figures are added together to establish the total height of the guidance pivot arm rotational center from the center of the spine.
Once the height of the pivot arm is set, lateral fluoroscopy is used to confirm the contact point of the arcuate pointer at the center of the disc space in the SI dimension, and is point of contact on an external surface of the subject's skin is selected as the incision site. In various embodiments of the guidance instrument the arcuate pointer has a radius of curvature from about 5 to 50 cm, including 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49 and 50, and incremental fractions thereof including 0.1, 0.2, 0.3, 0.4, 0.5, 0.6, 0.7, 0.8, 0.9 cm.
Instruments for Tissue Preparation
This disclosure provides a suite of tissue manipulation instruments that enable access to and manipulation of tissue with minimal invasion of tissue, and in certain embodiments, when used with the rail and bolster system as previously described herein, these instruments reduce or eliminate the percussive techniques that are common in most spinal surgeries. Of course, it will be understood that the instruments may be adapted for use in surgeries other than on the spine of an animal, and while representative embodiments are shown as curvilinear, other rectilinear embodiments are encompassed within the scope of the invention and may be useful for spinal and other applications.
Referring again to the drawings, alternate embodiments of instruments are shown including in
Referring now to
A representative embodiment of a surgical technique includes the following steps, the order of which is not intended to be limiting:
Position the Patient and Establish Incision Site
Position patient prone (and generally parallel to the floor) on suitable surgical table. Obtain CT scan to measure ventral to dorsal height of target vertebral space.
Radiographically or directly measure with a needle or wire the posterior soft tissue depth to spinous process over target disc space. (If procedure is open, this step is not required.)
Calculate total ventral to dorsal height and adjust incision guidance instrument guide height to enable direction of incision guidance instrument pointer to a position that is approximately 30% of the overall disc height from the posterior disc margin, based on the calculated disc height. (This is the target entry point into the disc space, dorsal to the midline of the disc along the frontal plane.) Rest exemplary represented instrument for measurement (“incision guidance instrument”) on patient (either on soft tissue for a closed procedure, or on spinous process if procedure is open) and use position indicators to roughly align with the spinal axis. Visualize with AP fluoroscopy to confirm collinear alignment with the spine along the sagittal plane and lateral alignment with the target disc space along the transverse plane. Engage incision guidance instrument pivot arm to approximate centerline of the disc space and visualize with lateral fluoroscopy to confirm. As needed, adjust fluoroscope position to achieve complete alignment of the image path and the incision guidance instrument, as confirmed in the fluoroscopy image. Mark skin to indicate cranial to caudal spinal midline, position of incision guidance instrument on the patient, and incision site to enable access at the target disc entry point.
Incision and Soft Tissue Dissection
Incise skin in a dorsal to ventral orientation, an exemplary incision width being approximately 4 cm. Using a Bovie, dissect through the subcutaneous tissue and muscles, and puncture through the Transversalis fascia into the retro peritoneum with a Kelly clamp. Manually enlarge the fascia incision and dissect the retro peritoneum towards psoas muscle, palpating the transverse process to confirm the posterior margin of disc space. Optionally, insert and engage retraction instrument(s), such as a bilateral speculum, in a cranial to caudal orientation to further expand the surgical field and expose the spine and associated soft tissue. Manually confirm nerve position relative to the psoas muscle to establish dissection point, and provisionally dissect.
Retractor Placement and Use of Surgical Tools
In some embodiments using a modular retractor as shown in some representative drawings, such as a curvilinear retractor, positioning and placement involves placing a first retractor having a distal end substantially adjacent to an anterior aspect of a spine at a target intervertebral space identified using the targeting method described above between a first vertebra and an adjacent vertebra, sliding adjacent to the first retractor a second retractor, the second retractor having a distal end that is adapted for manipulating soft tissue, manually directing the second retractor towards the spine and displacing the second retractor posteriorly and away from the first retractor so as to lift the soft tissue posteriorly/dorsally to enhance visualization of the spine, assembling the first and second retractors into engagement by coupling complimentary coupling elements at proximal ends of the retractors to form a channel between the two retractors having a longitudinal axis that runs distal to proximal, adjusting the coupled retractors pivotally around a pivot axis at their proximal ends to displace the distal ends of the retractors away from one another into an open position, and locking.
According to such embodiments, the method may also comprise selecting a tissue preparation device, affixing it the surgical support frame 200 on the adjustable pivot assembly 240, and proceeding with one or more of the following steps in the provided or any other order, including, inserting the tissue preparation device into the channel guided by the articulation path established by the adjustable pivot assembly 240 and into contact with the target vertebral space, the tissue preparation device fitted with a cutting instrument for penetrating a annulus of a disc within the target vertebral space, and actuating the drive component such as an impact plate on the tool to direct the cutting instrument into contact with the target vertebral space to penetrate the annulus; actuating the drive component to withdraw and replace the cutting instrument with another cutting instrument for penetrating a contralateral annulus of the disc within the target vertebral space, actuating the drive component to insert the tissue manipulator into contact with the target vertebral space to penetrate the contralateral annulus.
According to such embodiments, the method may also comprise actuating the drive component to withdraw and replace the cutting instrument with a distraction paddle that is adapted for rotating within the disc space to enhance distraction of the adjacent vertebrae, actuating the drive component to insert the tissue manipulator into contact with the target vertebral space to deliver the paddle distractor which is actuated to enhance distraction of the adjacent vertebrae; actuating the drive component to withdraw and replace the distraction paddle with an endplate scraper, and actuating the drive component to insert the tissue manipulator into contact with the target vertebral space to deliver the scraper which is actuated to withdraw disc material from the disc space. According to such embodiments, the method may also comprise actuating the drive component to withdraw and replace the endplate scraper with an implant trial, and actuating the drive component to insert the tissue manipulator into contact with the target vertebral space to deliver the implant trial to determine implant size. According to such embodiments, the method may also comprise actuating the drive component to withdraw and replace the implant trial with an implant, actuating the implant length adjuster to optimize centering of the implant in the disc space, actuating the drive component to insert the tissue manipulator into contact with the target vertebral space to deliver the implant, and actuating the release to deposit the implant in the vertebral space, and withdrawing the tissue preparation device from the channel
While the disclosed embodiments have been described and depicted in the drawings in the context of the human spine, it should be understood by one of ordinary skill that all or various aspects of the embodiments hereof may be used in in connection with other species and within any species on other parts of the body where deep access within the tissue is desirable.
While various inventive aspects, concepts and features of the general inventive concepts are described and illustrated herein in the context of various exemplary embodiments, these various aspects, concepts and features may be used in many alternative embodiments, either individually or in various combinations and sub-combinations thereof. Unless expressly excluded herein all such combinations and sub-combinations are intended to be within the scope of the general inventive concepts. Still further, while various alternative embodiments as to the various aspects, concepts and features of the inventions (such as alternative materials, structures, configurations, methods, devices and components, alternatives as to form, fit and function, and so on) may be described herein, such descriptions are not intended to be a complete or exhaustive list of available alternative embodiments, whether presently known or later developed.
Those skilled in the art may readily adopt one or more of the inventive aspects, concepts and features into additional embodiments and uses within the scope of the general inventive concepts, even if such embodiments are not expressly disclosed herein. Additionally, even though some features, concepts and aspects of the inventions may be described herein as being a preferred arrangement or method, such description is not intended to suggest that such feature is required or necessary unless expressly so stated. Still further, exemplary or representative values and ranges may be included to assist in understanding the present disclosure; however, such values and ranges are not to be construed in a limiting sense and are intended to be critical values or ranges only if so expressly stated.
Moreover, while various aspects, features and concepts may be expressly identified herein as being inventive or forming part of an invention, such identification is not intended to be exclusive, but rather there may be inventive aspects, concepts and features that are fully described herein without being expressly identified as such or as part of a specific invention. Descriptions of exemplary methods or processes are not limited to inclusion of all steps as being required in all cases, nor is the order that the steps are presented to be construed as required or necessary unless expressly so stated.
Lewis, Ryan, Garcia-Bengochea, Javier, Von Amsberg, Marc
Patent | Priority | Assignee | Title |
Patent | Priority | Assignee | Title |
10045768, | Jul 06 2014 | JGMG BENGOCHEA, LLC | Methods and devices for surgical access |
10687830, | Jul 06 2015 | JGMG BENGOCHEA, LLC | Methods and devices for surgical access |
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